(June 2003) Poor access to health facilities and low-quality health care delivery may be among the reasons that Zambia is facing increasing levels of maternal deaths. While many maternal emergencies can be prevented with prompt and appropriate lifesaving care, many of the women who die do not receive the attention of skilled health personnel.
Data indicate that the already high levels of maternal deaths are climbing. The 1996 Zambia Demographic and Health Survey (ZDHS) estimated that for every 100,000 live births, 649 women died as a result of obstetric complications.1 Latest figures from the ZDHS 2001/2002 indicate that the number has increased to 729 deaths per 100,000 live births. By contrast, estimates in neighboring Namibia are around 370 deaths per 100,000 live births, according to estimates from UN agencies.2
Medical Causes of Maternal Deaths
As with other developing countries, excessive bleeding is the main direct cause of death from obstetric complications. Other medical causes include infections, hypertensive disorders, obstructed labor, and complications from unsafe abortions. Other women die as a result of medical conditions that are aggravated by pregnancy or delivery, such as malaria, anemia, HIV, and cardiovascular disease. In Zambia, a 1997 Ministry of Health study found that AIDS contributed 12 percent of the indirect causes of maternal deaths.3
Specific findings on deaths from direct causes include the following:
- Excessive bleeding accounts for some 34 percent of maternal deaths, according to a study on funded by the United Nations Population Fund (UNFPA) in 1998.4 The study showed a higher incidence of hemorrhaging among deliveries in the villages (27 out of 48), compared with five out of 14 for those at health facilities.
- Infections, which often are a consequence of poor hygiene during delivery, account for some 13 percent of maternal deaths in Zambia, the report noted. Such infections can be prevented effectively by careful attention to clean delivery, according to the World Health Organization (WHO).5
- Obstructed labor, which occurs when the infant is unable to pass through the mother's pelvis either because of his or her position or the size of his or her head, accounts for 8 percent of maternal deaths in Zambia, the study concludes.
- Complications from unsafe abortions also account for a high number of maternal deaths, although abortion is legal in Zambia. The proportion of maternal deaths due to abortion increased from 13 percent in the 1970s to 30 percent by the early 1990s.6 A 1998 country profile by Zambia's Central Statistics Office (CSO) found that some 80 percent of women admitted to health care facilities with complications from induced abortions were younger than 19.7 Many deaths occur outside of these institutions and go unreported, however.
Ironically, Zambia has one of the most liberal abortion laws in southern Africa, but most women and health care providers are unaware of the legality and availability of abortion services. The 1972 Termination of Pregnancy Act allows access to safe abortion on medical or social grounds. Three physicians should approve the procedure, which must be performed at a clinic or hospital. In rural areas, each clinic has one health practitioner who uses his or her discretion to perform abortions. The client takes a chance because, should complications arise, the clinic may be unable to respond adequately.
The inability to provide obstetric care when emergencies arise is a major concern in parts of the country. A study conducted in the Southern Province district of Kalomo, which has 129 trained staff, two district hospitals, and 21 health centers, found that the institutions were unable to provide emergency obstetric care. They had no operating theaters or blood banks, according to the Prevention of Maternal Mortality program (launched in 2001 to provide technical assistance to district health management teams and nongovernmental health organizations working to reduce maternal deaths).8 The program's team leader, Rueben Mwape, said the research was indicative of what is obtained in most rural clinics and that there was an urgent need to correct the situation.
Economic Factors and Long Distances Limit Access to Care
Studies show that many women have limited access to skilled professionals for maternal care. For example, the 2001/2002 ZDHS shows that only 43 percent of mothers deliver with the assistance of skilled professionals, compared with 48 percent in 1996. In a report on research priorities and recommendations for action for 1999-2001, the Central Board of Health of Zambia noted a tendency among women to deliver at home as they got older.9 The report suggested that long distances to health centers might be a major reason for this. Others have also reported the trend. One study in Katete district in the Eastern Province said that as women grow older and have more children, long distances and the cost of care may become bigger concerns: "There seems to be a tendency among women as they grow older and with high parity to deliver at home without any assistance, maybe because of the long distance and the costs associated with a hospital delivery."10
People living in provinces and large towns along the railway line have better access to health centers. In urban areas, 99 percent of households are within 5 kilometers of a health facility, compared with only 50 percent of households in rural areas, according to the ZDHS 2001/2002.
Midwife Naphira Sichale agrees that distance and the cost of care are major issues. "People just do not have the money to pay the user fees or transportation costs, and it is usually too far to walk to the health center," she says, noting that women prefer to be delivered by their friends and relatives who charge nothing or by traditional healers who charge in kind.
Indeed, surveys show that the vast majority of women who die from obstetric causes in Zambia are in the middle- to poor-income groups. Only 3 percent of maternal deaths occur among women in high-income categories, according to the ZDHS 2001/2002. Health care services vary because of the two-tier fee system in the government-run hospitals. A woman in the low-cost section pays about K20,000 (US$4) and may get the attention of a clinical officer, a nurse or midwife (rarely a doctor), and medication if it is available. At the higher end, a payment of about K1 million (US$100) entitles a woman to a single or double room, a doctor on call, and full medical attention, notes a 1999 UNICEF report.11
Social and Cultural Barriers to Care
Other social and cultural factors determine whether or not women visit health care facilities. Many say the services are disrespectful to women. According to the 1998 UNFPA-supported study, women complain of bad attitudes by health care workers. Some say the nurses shout at mothers for not buying things like razor blades, baby clothes, and gloves (hospitals no longer provide these items). The presence of male nurses is also off-putting.
"It is uncomfortable to have a man examine you, and besides, it is culturally taboo for a man who is not your husband to see anything above the knee," says Sichale.
Adherence to some tribal customs also increases the risk of maternal deaths. Among these customs, women drink herbs that they think will help them deliver quickly, the UNFPA study notes. The concoctions are often homemade, sometimes toxic, and prepared in unhygienic conditions. All this increases the risk that the mother could have sudden vomiting or diarrhea while in labor. Among other customs, some women are taught to insert their fists or other objects into the vagina to help it "expand" in readiness for birth. It is also taboo in some communities to inform husbands about complications, especially when they relate to excessive bleeding. He is informed only when the condition is far advanced — a delay that further impedes any decision to seek care.
One study found that few in Kalomo were able to recognize obstetric emergencies and many traditional beliefs and practices delayed patients' decision to seek health care. The 1998 maternal mortality ratio for the area was 824 per 100,000 live births, well above the national average of 649.12
Actions To Save Mothers' Lives
Several initiatives are in place to try to reduce the number of maternal deaths. The government, with UNICEF support, launched the Zambia Safe Motherhood Initiative in 1987 in an effort to halve the number of maternal deaths. The government decentralized health facilities and set up district health management teams. Health workers were also posted to remote areas in a bid to raise the standard of care and increase the quality of services. Clinics have been upgraded and more than 100 traditional birth attendants have been trained to assist in home deliveries.
The Maternal and Neonatal Health (MNH) project, supported by the United States Agency for International Development (USAID), set up a national office in Zambia in 2000 to strengthen essential maternal and neonatal services, using the following strategies:
Improved delivery of services: The program, which seeks to strengthen education and clinical training, has worked to revise the registered midwives curriculum and to develop a package that includes guides for tutors and learners and a manual of procedures.
Behavioral change interventions: The Zambia White Ribbon Alliance for Safe Motherhood, launched in 2001, serves as the focal point of the social mobilization strategy of the MNH project. This strategy includes communicating key health messages via mass media programs. The program has provided technical input to a number of activities, notably the Better Health Campaign (a multimedia communication program) and a distance education program to help neighborhood health committees sensitize and mobilize communities around such issues as preparing for birth, recognizing obstetric complications, and understanding postpartum needs.
Policy and advocacy: Working with the General Nursing Council of Zambia, the MNH project is lobbying for the revised registered midwives curriculum to be used as the basis for updating national technical guidelines for health center staff. Complementing these will be new guidelines by WHO: "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors."
Among the latest interventions is the pilot project for women-friendly services, set up in Lusaka in 2000. Rosemary Kumwenda, who founded the project, says maternal services should be of high quality, accessible, affordable, culturally acceptable, and satisfy the needs of women, particularly poor women who are at greater risk and have fewer communication skills than women in higher income brackets. "We want services that are not only baby-friendly but mother-friendly as well," she says.
The project conducted a pilot survey in Lusaka's clinics and produced a practical guide, based on the experiences and responses of expectant mothers. The guide, which aims to provide low-cost tools for improving services in poor settings, begins with the premise that both technical and emotional care are essential to good maternal health. Among other things, the guide recommends that women be addressed in their native language and that a more professional and respectful relationship develop between traditional birth attendants and medical staff.
"For us, it is not so much more resources, but a more positive attitude of health care providers to clients and vice versa," said Kumwenda. "We want a more cordial and mutually rewarding relationship."
Zarina Geloo is a freelance journalist based in Zambia.
- Central Statistical Office (CSO) and Macro International Inc., Zambia Demographic and Health Survey, 1996 (Lusaka, Zambia: CSO and Macro, 1995).
- CSO and Macro International Inc., Zambia Demographic and Health Survey, 2001-2002 (Lusaka, Zambia: CSO and Macro, 2003).
- Zambian Ministry of Health and Central Board of Health (CboH), HIV/AIDS in Zambia: Background, Projections, Impacts Interventions (Lusaka, Zambia: Ministry of Health and CboH, December 1997).
- B.G. Nsemukila, A Study of Factors Contributing to Maternal Mortality in Zambia (Lusaka, Zambia: UNFPA, 1998).
- World Health Organization (WHO), "Reduction of Maternal Mortality: A Joint WHO/UNFPA/UNICEF/World Bank Statement" (WHO: Geneva, 1999).
- Ministry of Health and Family Care International, Safe Motherhood in Zambia — A Situation Analysis (Lusaka, Zambia: Ministry of Health, 1994).
- CSO, Country Profile 1998 (Lusaka, Zambia: CSO, 1999).
- R. Mwape, Needs Assessment (Lusaka, Zambia: Prevention of Maternal Mortality Program, 2002).
- CboH, Zambia National Health Research Agenda: National Health Research Priorities and Recommendations for Action 1999-2001 (Lusaka, Zambia: CboH, February 1999).
- C.L. Sitali, A Study of Home-Based Deliveries in Katete District (Lusaka, Zambia: University Teaching Hospital, 1999).
- United Nations Children's Fund (UNICEF), Reducing Maternal Mortality and Morbidity (Lusaka, Zambia: UNICEF, 1999).
- United Nations Development Programme (UNDP), Civil Society for Poverty Reduction, What Can We Do About Poverty in Zambia? (Lusaka, Zambia: UNDP, 2002); and UNDP, Programme Review and Strategy Development Report (Lusaka, Zambia: UNDP, 2002).
For More Information
Zambia Integrated Health Programme: www.zihp.org
University of Zambia Medical Library: www.medguide.org.zm
For more on maternal mortality in the developing world, read PRB's report Making Motherhood Safer: Overcoming Obstacles on the Pathway to Care (PDF: 734KB).